Nps Form 10-930s - Application For Special Use Permit (Page 2 of 2) in pdf

NPS Form 10-930s (Rev. 07/2016)

OMB Control No. 1024-0026

National Park Service

Expiration Date 1/31/2020

NOTICES

This is an application only, and does not serve as permission to conduct any special activity in the park. The information provided will

be used to determine whether a permit will be issued. Send the completed application along with the application fee to the park

address found on the first page of this application or email to holly_fetzer@nps.gov.

You can pay electronically (Debit or credit card, Bank account (ACH), Amazon account, or PayPal account) or you can also pay by

business or cashier’s check or money order made payable to: Minuteman Missile NHS in the amount of $100.00.

For electronic payment, we will issue you an e-bill. To request an e-bill, contact us at 605-279-2367 or holly_fetzer@nps.gov.

All other forms of payment can be mailed to the address found on the first page of this application.

If your request is approved, a permit containing applicable terms and conditions will be sent you. The permit must be signed by the

responsible person and returned to the park for final approval by the Park Superintendent before the permitted activity may begin.

Privacy Act Statement

Authority: 16 U.S.C. 1, National Park Service Organic Act; 16 U.S.C. 3, Rules and regulations of national parks, reservations, and

monuments; timber; leases, 16 U.S.C. 3a, Recovery of costs associated with special use permits; and 16 U.S.C. 460i–6d, Commercial

Filming.

Purpose: The purposes of the system are (1) to provide a park superintendent with information to approve or deny requests for

activities that provide a benefit to an individual, group or organization, rather than the public at large; and (2) to assist park staff to

manage the activity to ensure that the permitted activity does not interfere with the enjoyment of the park by visitors and that the natural

and cultural resources of the park are protected.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information

contained in this system may be disclosed outside the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other

Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals based on an authorized

routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of

records notice for this system.

Disclosure: Voluntary, however, failure to provide the requested information may impede individual from obtaining a permit from the

National Park Service.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security

Number (SSN) is needed to identify records unique to you. Applicants are required to provide their social security or taxpayer

identification number for activities subject to collection of fees and charges by the National Park Service. Failure to disclose your SSN

may prevent or delay the processing of your application. The authority for soliciting your SSN is 31 U.S.C. 7701. The information

gathered through the use of the SSN will be used only as necessary for processing this application and collecting and reporting any

delinquent financial obligations. Use of the social security number will be carried out in accordance with established regulations and

published notices of system of records.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers the

information needed to decide whether or not to allow the requested use. All applicable parts of the form must be completed in order for

your request to be considered. You are not required to respond to this or any other Federal agency-sponsored information collection

unless it displays a currently valid OMB control number.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 15 minutes per response including the time it takes to read, gather and

maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form,

to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192.

Please do not send your form to this address.

Page 2 of 2

Nps Form 10-930s - Application For Special Use Permit Page 2

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